Ortho Op Report Clavicle resection

AR2728

Expert
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Perryville, MO
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My ortho clinic has my brain on overload...I'm not sure on exactly the correct procedure or even ICD for th clavicle excision in this report:

Patient previously had ORIF of right clavicle, then fell 4 days after surgery and it was noted later hardward was becomming exposed.

Preop diag: clavicle exposed hardware
Proc: hardware removal and clavicle resection

The patient had a clavicle plate intact however, there was a new fracture more medial to the plate which had subsequently fractured after her latest fall. At this point in time, the clavicular plate was removed. Due to the comminution of the fracture, it was determined to not fix the fracture and a small portion of the clavicle medially was removed to prevent tenting of the skin. The sides of the clavicle were smoothed down. The wound was copiously irrigated with normal saline......

I have the ICD and CPT for the exposed hardware. I'm lost on the clavicle resection and the correct ICD for that procedure. I found 23120 and 23180---would I use exposed hardware as the diagnosis for the resection--or an active fracture code?
 

JMeggett

Guru
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226
Location
Spokane Valley, WA
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My ortho clinic has my brain on overload...I'm not sure on exactly the correct procedure or even ICD for th clavicle excision in this report:

Patient previously had ORIF of right clavicle, then fell 4 days after surgery and it was noted later hardward was becomming exposed.

Preop diag: clavicle exposed hardware
Proc: hardware removal and clavicle resection

The patient had a clavicle plate intact however, there was a new fracture more medial to the plate which had subsequently fractured after her latest fall. At this point in time, the clavicular plate was removed. Due to the comminution of the fracture, it was determined to not fix the fracture and a small portion of the clavicle medially was removed to prevent tenting of the skin. The sides of the clavicle were smoothed down. The wound was copiously irrigated with normal saline......

I have the ICD and CPT for the exposed hardware. I'm lost on the clavicle resection and the correct ICD for that procedure. I found 23120 and 23180---would I use exposed hardware as the diagnosis for the resection--or an active fracture code?
I think 23120 fits nicely for what is documented here and I would use 810.00 with it. This obviously is unrelated to the original Sx and so I would attach -79 to the CPT. I think the hardware removal too is totally unrelated to the original Sx...if she hadn't refallen would the hardware have been exposed? Likely not :) But of course you'll need to send documentation with the claim and then watch closely in case insurance tries to deny as in global.
Jenna
 
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